LAFAYETTE GARDENS

Official classification

Type B

Official code

87507

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements Based on interview conducted, Resident 1 (R1) has a diagnosis of Dementia and trying to get in contact with R1 POA to get all the documentation sign. Documents that was being provided is from the previous facility and not for this facility.

Official plan of correction

By POC date Administrator agree to obtained R1 admission agreement, and all require document sign by R1 representative.

Deadline recorded: May 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(1)

Regulation authority

CCR

What the official deficiency says

87705 (b)(1) Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. 87705 (b)(1) Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.

Official plan of correction

The administrator will review facility’s plan of operation regarding procedures for notifying the resident’s physician, family members, or conservator when a resident’s condition or behavior changes. Administrator will submit to CCL self-certification of understanding by POC date

Deadline recorded: Aug 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705(b)(2) Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on interviews and record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors. Administrator and facility staff interviewed state R1 was observed crawling under the bed, throwing flowerpots inside the room and pulling down picture frames on the wall. Despite observing R1’s aggressive behaviors, the facility did not provide safety measures to prevent R1 from sustaining bruises on both arms and a cut on R1’s left biceps which poses an immediate threat to the health and safety of clients under care.

Official plan of correction

The administrator will review all residents Physician’s Reports and update Appraisal Needs and Services Plan addressing resident behaviors such as wandering and aggressive behavior. Administrator will send copies of updated care plan by POC date.

Deadline recorded: Aug 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.. This requirement is not met as evidenced by: Based on interviews conducted, staff observed R1 with bruise, agressive, crawling under the bed, breaking pot plants but no medical appointment was arranged which poses a potential risk tohelath and safety of clients under care.

Official plan of correction

By POC date, Administrator will review all resident files and ensure that all residents are current with medical/dental appointments. Administrator will self-certify completion and send to CCL.

Deadline recorded: Aug 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(1)

Regulation authority

CCR

What the official deficiency says

87705 (b)(1) Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes. This requirement is not met as evidenced by: Based on interviews and record reviews conducted, facility did not notify R1’s Responsible Person on R1’s change in condition which poses an immediate risk to health and safety of clients under care.

Official plan of correction

The administrator will review facility’s plan of operation regarding procedures for notifying the resident’s physician, family members, or conservator when a resident’s condition or behavior changes. Administrator will submit to CCL self-certification of understanding by POC date.

Deadline recorded: Aug 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705(b)(2) Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on interviews and record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors. Administrator and facility staff interviewed state R1 was observed crawling under the bed, throwing flowerpots inside the room and pulling down picture frames on the wall. Despite observing R1’s aggressive behaviors, the facility did not provide safety measures to prevent R1 from sustaining bruises on both arms and a cut on R1’s left biceps which poses an immediate threat to the health and safety of clients under care.

Official plan of correction

The administrator will review all residents Physician’s Reports and update Appraisal Needs and Services Plan addressing resident behaviors such as wandering and aggressive behavior. Administrator will send copies of updated care plan by POC date.

Deadline recorded: Aug 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents who have dementia didn't updated physician's report annually which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2023 Plan of Correction Administrator agrees to review regulation section code 87705, and submitted a self-certification of understanding to CCL by the POC due date.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative…once every 12 months… This requirement is not met as evidenced by… This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 5 residents didn't update needs and services plan annually on file poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2023 Plan of Correction Administrator agrees to review regulation section code 87463, and submit a self-certification of understanding to CCL by the POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and records review, licensee did not comply with the section cited above. LPA observed centrally stored medications in the dinning room was left unlock which poses an immediate health, safety risk to persons in care.

Official plan of correction

POC Due Date: 02/19/2022 Plan of Correction Caregiver locked up the centrally stored medication during visit. In addition, Administrator will conduct in-services training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due date.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed unlocked knives in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/19/2022 Plan of Correction Caregiver locked up the knives in the centrally stored medication cabinet during visit. In addition, Administrator will conduct in-services training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due date.